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Nur 211 > Hour11 > Flashcards

Hour11 Flashcards

1
Q

Spina Bifida

A

tuft of hair o dimple where buttcheeks separate
skin is closed

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2
Q

Meningocele

A

bulge meninges sac of CSF with no nerve involvement no paralysis

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3
Q

Myelomeningoclele

A

protrusion of meninges with CSF + nerves
-more likely to have bowel problems, paralysis + weakness
-Increased concern for infections

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4
Q

Screening for spina bifida + Detection

A

16 to 18 weeks/ Alpha fetoprotein test

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5
Q

Repair for Spina

A

48-72hrs

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6
Q

Nursing Care for spina

A

PROTECT TISUES WITH STERILE MOIST DRESSING+ OCCLUSIVE.
Postiion child prone off defect

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7
Q

Kidney rt spina

A

urinary catheter to prevent infect
Crede Bladder
suprapubic so that you aren’t positiong the child on their defect to re cath often

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8
Q

Neurological

A

Check finger+ toes, rooting
Chek ICP
VP shunt: drains out the fluid and decrease ICP
Hydrocephalus: pressure cause brain/skull seen in myelomeningcole pts look for ICP increased, blocked shunt, leaking CSF, head circumfrence

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9
Q

Hydrocephalus ( define/ s+s)

A

increased fluid in ventricles they route CSF in brain.causing the ventricles to enlarge which puts pressure on the brain tissue resulting in brain damage

s/s = head circumference
Bulging Fontanels
irritability, high pitched cry, nuchal rigidity
vomiting
feeding difficulties
increased frontal lobe
plate scratching sound
transillumination = increased red in head
sunset sign= eyes appear downward ; white of eye visible
prominent veins

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10
Q

Childhood vs Infancy Hydrocephlaus s/s

A

Infancy: skull veins, increased ICP, cry, irritable, increased head circumference, bludging anterior fontalles, cracked pot sound
transillumination = increased red in head
sunset eyes - eyes deviate downward

Childhood
Focal manifestation
Headache
Irritable
Confused

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11
Q

Tx of hydro

A

a shunt is inserted to drain into peritonea cavity
mointo for chnage in neurlogical status

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12
Q

Post op

A

postion off shunt
continue assements for meningitis
ICP increased
Blocked shunt
Leaking CSF ( halo or glucose test) * what color should it be?*
Head Circumference

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13
Q

Cleft Lip

A

development of lip isnt developed in utero can see in ultrasound
can be complete (involvement nasal passage) or incomplete

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14
Q

Nurse/Delivery for cleft lip

A

keep neural dace and reaction

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15
Q

Pre-op Care for cleft lip

A

support family
can breastfeed with adaptations to stimulate deeding and mom pumps
meet infant sucking need with pacificer usage during g tube
Feed upright
skin stretchers may inserted prior surgery to increase amount of skin available to graft to ne areas
Piegon bottles
BURP FREQUENTLY

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16
Q

Complications rt cleft lip

A

Aspiration pneumonia
FTT
Decreased bonding
Infections (ear + respiratory)

17
Q

Post Op care rt cleft lip

A

Positioning SUPINE ONLY

Logan Bow/bar = protect inscions - remove during feedings

Rinse mouth after feeding, incsion+ wound care
Arm restraints to prevent touching of site
HOB up (infant seat) help decrease swelling / propped on side
Feeding resumes when cleared
NO SPOONS ( requires movement of lips)
Prevent crying (bonds+ pain meds)

18
Q

Post op issues rt cleft lip + plate

A

Infection (ear+ lung dt opening)
Disruption of suture line
Speech problems
FTT
nutrion alterations

19
Q

Cleft Palate

A

Incomplete closure of palate @9 weeks gestation

20
Q

Surgical interventions

A

Between 1-2 1/2
Before speech patterns

21
Q

Preop Cleft Palate

A

BURP MORE FREQUENTLY
Retainer; special nipple for feeding
Long, soft nipples and bottles ( plastic or silicone spoon)
May use GT ensure adequate intake

22
Q

Post Op Cleft Palate

A

Oral care, protect site
Pain relief , no specially postion requirements
No-No ( restraints)
Games to develop speech/word
SOFT foods . careful with spoon

23
Q

Tracheoesophageal Fistula and Esophageal Atresia

A

TEF: abnormal connection between upper part of esophagus and trachea/windpipe
EA: when upper part of esophagus does not connect with lower esophagus/stomach

24
Q

S/s of TEA + EA

A

3 C’s = cough, choking, cyanosis with first feed
Frothy saliva in mouth _nose, drooling
Monitor first fed stop immediately notify MD
Respiratory Distress during feeding
Abdominal distention
Aspiration pneumonia
IVF, G tube

25
Q

Pyloric Stenosis:

A

hypertrophy (enlargement of muscle around sphincter) and hyperplasia (enlargement
of tissue) of pyloric sphincter
decreases flow of food through pylorus from stomach to duodenum

26
Q

S/S of Pyloric Stenosis

A

3wks: regurgitation of breast + formula

-4-6wks: projectile vomiting in healthy infant (up to 3hrs after eating), no bile in vomit
- May progress to malnutrition, metabolic alkalosis hypokalemia , dehydration (sunken fonatlle)
, FTT ( nto retaining anything)
- May feel olive sized firmness at pylorus Palpable right epigastric region ( hypertriphied pllorus )
- See waves of peristalsis across abdomen

27
Q

Treatment Pyloric Stenosis

A

Least invasive to first
1. thickened foods, elevated 30 minute after eating

then
Endosopcic dilation = ballon inssterd to expand opening
laparoscopic plyrmyotomy : cuts muscle thru abdomen

28
Q

Nurse Dej job rt Pyloric Stenosis

A

-Fluid and electrolyte balance

-Daily weights

  • Meet infant needs: bonding, pain relief
  • Oral feedings immediately after surgery (Breastfeed/formula)

Clear liquids and advance as tolerated ( 1/2 strength then full stength )

  • No pacifier, Burp well- decrease air intake
29
Q

HT rt pyloric stenosis

A

Vomiting is normal
S/S dehydration , resuming BF/formula
Infection HRF SEPSIS

30
Q

Hirschsprung’s Disease:

A

lack of normal peristalsis due to absence of autonomic parasympathetic
ganglion cells; No movement in bowels, leads to retention of stool, distention of bowels ( mechanical obstruction)

31
Q

S/S rt Hirschsprung’s Disease

A

Distended abdomen
Feeding intolerance
Billious vomit ( key difference)
Delay in passage of meconium
Constipation
ribbon like stools
Enterocoliits

32
Q

Nursing Responsibilities: Hirschsprung’s Disease

A

Removal of intestine
Temporary colostomy
S+S of wound infection + bowel obstruction
Appetite
Abdomen
Weight

33
Q

Intussusception:

A

telescoping of a portion of the intestine into an adjacent portion; common at six months to 6 yrs

compression on blood vessels leading to possible necrosis

34
Q

Intussusception s/s

A

sudden onset of abdominal cramp pain
bilious vomiting
tender distended abdomen at umblical area
currant jelly stool ( purple color , dark red), mucousy
LOOSE SCANT STOOLS

35
Q

Tx of Intusssuscpetion

A

Liquid or air enema to “reopen intenstines” (ASAP)
Surgical repair if doesnt work

Nur 211 (2 decks)

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